Inspection on 13/06/06 for Pollard House

This inspection was carried out on 13th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Pollard House 21/06/07

Pollard House 16/01/07

Pollard House 26/01/06

Pollard House 24/08/05

Pollard House 31/08/04

Pollard House 20/04/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Pollard House 68 Pollard Lane Undercliffe Bradford West Yorkshire BD2 4RW Lead Inspector Mary Bentley Unannounced Inspection 13th June 2006 09:00a X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Pollard House DS0000056120.V297911.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Pollard House DS0000056120.V297911.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pollard House Address 68 Pollard Lane Undercliffe Bradford West Yorkshire BD2 4RW 01274 636208 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (If applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Chander Shekher Kainth Mr Sohan Lal Kainth Care Home 28 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (16), of places Physical disability over 65 years of age (2) Pollard House DS0000056120.V297911.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th January 2006 Brief Description of the Service: Pollard House is an adapted Victorian building providing personal care for twenty-eight service users. The home offers care to people over the age of 65 and has 10 places registered for the care of people with dementia. There is a lounge on the lower ground floor, which is a designated smoking area for residents. There are two lounges and a dining room on the ground floor. There are bathrooms, assisted showers and toilets on each floor near to lounges and bedrooms. There is a small garden at the front the building. The home is situated on a bus route and is approximately one mile from Bradford city centre. There is limited car parking at the rear of the building with additional roadside parking. The weekly fees range from £308.14 to £334.75, no top up fees are charged. Hairdressing and chiropody are charged as extra. Pollard House DS0000056120.V297911.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk This was an unannounced inspection; it took place over two days, 13 & 14 June 2006. On the first day two inspectors were in the home from 9.00am until 3.30 pm and on the second day one inspector visited the home between 10.00am and 2.15pm. The last inspection took place in January 2006. Since then there has been one additional visit to the home. There has been one Adult Protection issue since the last inspection; the investigation is still in progress. The purpose of this inspection was to check if the requirements identified at the inspection in January 2006 were being dealt with and to assess the quality of care being provided to residents in the home. During the inspection we assessed all the key standards, these are identified in the main body of the report. We looked in detail at the care of three of the 19 residents in the home. We looked at their care records, we spoke to the residents about their care needs and to the staff about how they deliver care, we looked at the environment in which these residents receive care and observed care practices. We also spoke to other residents in the home, carried out a tour of the building and looked at other records included maintenance records, staff files and training records. Information was requested from the home prior to the visit, this was provided and was used during the inspection. We spoke to visitors in the home during the inspection. Comment cards for residents and relatives were left at the home; these provide people with an opportunity to share their views of the service with the CSCI. Information obtained in this way is discussed with the owner without identifying who has provided it. No comment cards from residents or relatives had been returned at the time of writing this report. Comment cards were also sent to a number of GP practices, one was returned and indicated overall satisfaction with the home. Detailed feedback was given to the owner and acting manager at the end of the visit, this included an Immediate Requirement Notice. More detail about Pollard House DS0000056120.V297911.R01.S.doc Version 5.2 Page 6 this notice is provided in the “What they could do better” section of this summary. What the service does well: What has improved since the last inspection? What they could do better: Improvements are required to all aspects of the service; all the outcome groups were looked at and judged to be either “poor” or “adequate”. The home has not had a registered manager for two years and this is now having a major impact on the service. There is clear evidence of lack of leadership and until this is dealt with it is difficult to see how the service can progress to achieving “good” or “excellent” outcomes for people using the service. Despite the fact that the home is registered to provide care for people with dementia there is no evidence that the staff have the knowledge and skills needed to provide this care. It is a cause of great concern that the training that has been provided does not appear to have led to any improvements in the service. For example staff have received training on dealing with medicines but an Immediate Requirement Notice was issued because Insulin was not being stored safely in the home. Another example is that unsafe practices in moving and handling were observed despite the fact that staff have been trained in this area. Pollard House DS0000056120.V297911.R01.S.doc Version 5.2 Page 7 There are very few opportunities for the majority of residents to take part in any meaningful activity or to exercise choice and control over their lives. For example residents do not know what they are having for lunch until it is served. Some residents said they were bored and one regular visitor to the home said, “Its dead here, nothing ever happens”. There was no evidence that there is an awareness of equality and diversity within the service. Requirements have been made about these and other issues identified in the report. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Pollard House DS0000056120.V297911.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Pollard House DS0000056120.V297911.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 3. Standard 6 does not apply to this service. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. Information about the home is not up to date; this makes it difficult for propective residents and/or their representatvies to make an informed decision about the suitability of the to meet their needs. The terms and conditions do not make it clear what residents will be charged for additional services. The needs of residents are assessed before they are admitted to the home. EVIDENCE: The Statement of Purpose is not up to date and is not presented in format that is appropriate to the needs of residents. The acting manager said he was working on a new Statement of Purpose and Service User Guide. He said he was aware of the need to make these documents easier to use and the revised documents would be in larger print and include pictures. Pollard House DS0000056120.V297911.R01.S.doc Version 5.2 Page 10 The Terms and Conditions of residency set out what services are included in the fees and what services are available at an additional cost, however there is no information on the charges for additional services. A pre admission assessment had been done for the resident most recently admitted to the home but there was no information about who carried out the assessment or when it was done. Pollard House DS0000056120.V297911.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8, 9 & 10 Quality in this outcome area is poor. This judgement has been made using the available evidence including a visit to the home. The care plans do not set out in detail how the personal, health and social care needs of residents will be met therefore there is a risk that residents’ needs will be overlooked. Residents are not protected by the home’s systems for dealing with medicines. Overall the privacy and dignity of residents is respected although some working practices create the opportunity for privacy and dignity to be compromised. EVIDENCE: There was no index to show the areas covered by the care plans therefore it was not easy to see at a glance which areas of care had been prioritised. The care plan files were full of out of date paperwork making it difficult to get an accurate picture of people’s current needs. Pollard House DS0000056120.V297911.R01.S.doc Version 5.2 Page 12 The care plans did not give detailed instructions for staff to follow. There were no care plans to show how spiritual needs were to be met. The care plan should include the person’s wishes about end of life care. The recording of incontinence was poor; and in some cases the incontinence pads seen in residents’ rooms were not the ones specified on the forms. The personal hygiene charts showed that one resident had not had a bath since 02/05/06 and another had not had a bath since 28/04/06. The care plans contained nutritional risk assessments but in the case of one resident who was losing weight this had not been reviewed for several months. The records showed that the District Nurses had made a referral to the dietician in July last year but there was no information to say whether this had been followed up or not. The moving and handling assessments did not give enough information on the level of help needed by residents and on two occasions staff were observed using unsafe moving and handling techniques. There was no information about how the mental health care needs of residents are dealt with. Some of the records suggested staff do not really understand how short-term memory affects people’s day-to-day abilities. For example, putting the responsibility for managing a potentially difficult situation back on the resident and not taking account of the fact that the resident was likely to have difficulty remembering what had been agreed. The recording of visits by other professionals such as chiropodist, dentist and optician was sketchy. The deputy said that when residents need a dentist the home has to contact NHS Direct to have a dentist allocated. There was very little information in the daily records about how people living in the home actually spend their time. There were gaps on the medication charts meaning that it is not possible to check if residents have received their prescribed medicines or not. A number of the charts did not have photographs of residents. Insulin was being stored in individual residents’ bedrooms but was not locked up creating a serious risk to other residents. During the visit the insulin was removed to a locked storage cupboard. An Immediate Requirement Notice was issued about this. During the January 2006 inspection medication practices were also identified as a major concern and an Immediate Requirement Notice was issued at that time. It is therefore both worrying and disappointing to find that management of the home has not done more to safeguard the wellbeing of residents. Generally residents’ privacy was respected but the practice of propping doors open potentially compromises the privacy and dignity of residents. Other observed practices that compromised residents’ privacy and dignity were discussed during feedback. Pollard House DS0000056120.V297911.R01.S.doc Version 5.2 Page 13 Pollard House DS0000056120.V297911.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the home. There are limited opportunities for most residents to take part in social/leisure activities appropriate to their needs and preferences. There are limited opportunities for less able residents to exercise choice and control over their lives Residents said the food was good but they have little control over what they are given to eat. EVIDENCE: It was disappointing not to see more personal background information in case files. As care plans do not identify individual interests residents fit in with the activities staff provide (if any) rather than having activities tailored to their interests. However one resident spoke of the mornings exercise activities she attends the community centre and said what a good time she had. Other residents appeared bored and fed up. One resident kept asking for a drink of tea it was a good half hour before staff attended to her. Pollard House DS0000056120.V297911.R01.S.doc Version 5.2 Page 15 The home is planning a trip out for residents and while this is commendable more attention must be given to how residents are supported in occupying their time meaningfully on a day-to-day basis. One regular visitor to the home said there are never any activities and she was surprised to see staff playing dominoes with residents’ as she had never seen this happen before. A visitor said she always visits her relative in the lounge, they have never been offered the opportunity to have their visits in private. One resident said her bedroom was used as a “dumping ground”. A mattress had been left in there and she asked several times for it to be moved so that she could use her room, it was removed but only after she had become visibly upset. Residents said they go to bed and get up when they want and can choose whether to spend their time in the communal rooms or in their bedrooms. The radio in dining room was tuned to Galaxy FM and there was no evidence to suggest this was the residents preferred choice of listening. Most residents spoke well of the food although they said they have no idea what the meal of the day will be until it is served. At lunchtime staff were seen encouraging and helping residents to eat and one resident was given a plate of sandwiches at her request. The menus provided by the home did not have information on what is available for breakfast and did not show that any alternatives are offered for the evening meal. There is no clear dietary plan for people with diabetes to ensure their diet is as varied and interesting as possible. Pollard House DS0000056120.V297911.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the home. The complaint procedures are not widely available in the home and therefore residents and/or their representatives cannot be confident that their complaints will be taken seriously and acted upon. A lack of understanding of how to apply Adult Protection procedures in practice creates the opportunity for residents to be placed at risk. EVIDENCE: The home has a system for recording complaints. There was no evidence that the complaint procedures are made widely available in the home. Residents said they were not sure how to complain. One said “you tell the staff don’t you, they look after you’” and another said she would talk to the deputy. Despite the fact that the majority of staff have now attended Adult Protection training the manner in which a recent incident of alleged abuse was dealt with suggests a lack of understand of how to apply Adult Protection procedures in practice. Pollard House DS0000056120.V297911.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, 24, 25 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. Improvements have been made since the January inspection in relation to the safety of the environment, however the practice of propping doors open with wedges comrpises the fire safety of the building. Some improvements have been made to the fabric and furnishings and further improvements are planned, this should create a more pleasant place for people to live. Generally, the home was clean however there were unpleasant odours in a number of areas. EVIDENCE: There are a variety of pleasant communal rooms but the lack of natural ventilation in some areas causes a build up of unpleasant odours. The refurbishment programme is ongoing. Some corridors have been painted and Pollard House DS0000056120.V297911.R01.S.doc Version 5.2 Page 18 carpets throughout the building are due to be replaced. Once this is done there should be an improvement in controlling the odours in the home. All the requirements made by the Environmental Health officer about the kitchen must be addressed. The gardens were overgrown. In some bedrooms residents had their personal belongings around them but other bedrooms were very basic. A number of bedroom doors were propped open with door wedges. The maintenance records showed that the hoists and lifts have been serviced. Hot water temperatures are checked monthly and a bath thermometer is now available. Pollard House DS0000056120.V297911.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is poor. This judgement has been made using the available evidence including a visit to the home. Most of the time there are enough staff on duty to meet residents’ needs Despite the fact that more staff training has taken place this does not seem to have made any significant difference to the quality of life experienced by people in the home. The lack of training on dementia care seriously compromises the ability of staff to meet the needs of this resident group. Despite the fact that recruitment procedures have improved the management of the home do not seem to appreciate their responsibilites with regard to the employment of staff with criminal convictions thereby placing residents at unnecessary risk EVIDENCE: The duty rosters showed that there are three care staff on duty during the day and two at night. The acting manager and former acting manager work Monday to Friday. There are no housekeeping staff on duty at the weekends which means that care staff have to attend to these duties. The roster on the first day of the inspection was not accurate, it showed both the acting manager and former acting manager as being on duty, however neither were actually working in the home that day. There was insufficient information on the roster about agency staff employed Pollard House DS0000056120.V297911.R01.S.doc Version 5.2 Page 20 Three staff files were looked at and showed that references and CRB (Criminal Record Bureau) checks had been received before new staff started work in the home. The home has recently employed a member of staff with a criminal conviction and there was no evidence that a risk assessment had been carried. During the inspection in January 2006 concerns were raised about another member of staff with a criminal conviction and inadequate references, this situation remains unresolved. Five care staff have an NVQ (National Vocation Qualification), this equates to 35 of the care staff workforce. The home has plans to enrol more care staff on NVQ training. The home has an induction checklist for new staff and the manager has started to work throught the Skills for Care induction standards with four members of staff. Some training is taking place on infection control, medicine administration and health and safety. The majority of staff have attended Adult Protection training. No training has yet taken place on dementia care. A recently appointed member of staff said she had attended workshop on moving and handling and fire safety. She said she had not received any real induction during the early days of her employment. A young girl on placement from school also stated she did not receive any induction and had very little supervision whilst at the home. Pollard House DS0000056120.V297911.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37 & 38 Quality in this outcome area is poor. This judgement has been made using the available evidence including a visit to the home. The home has been without a registered manager for two years and the findings of this inspection clearly indicate a lack of leadership. While there have been some improvements in health and safety these have been mainly environmental and the home has made little or no progress towards demonstrating that it is run in the best interests of residents. EVIDENCE: The home has not had a registered manager for two years. At the time of the January 2006 inspection there was an acting manager in post, following the inspection she withdrew her application to be registered. She continues to work at the home although it is not entirely clear what her current role is. A management consultant was appointed and he is now the acting manager. The CSCI have not received an application for him to be registered. Pollard House DS0000056120.V297911.R01.S.doc Version 5.2 Page 22 Discussions with staff indicated that there is a lack of clear leadership in the home and lines of responsibility are not clearly defined. Discussions with residents suggested that neither the current nor the previous acting managers have a very visible presence in the home. Residents identified the deputy as the person they would speak to if they had any concerns. The owner visits the home regularly, the CSCI has received one report from a monthy visit where all aspects of the service were reviewed by the owner. He said he had done another visit but the report had not been yet been prepared. The acting manager said he is aware of the need to develop a quality assurance system. He said he is trying to get the families and/or representatives of residents involved in care reviews, so far he has completed four. Staff meetings are held and the home has started to have residents meetings. The staff spoken to were not aware of what was discussed in residents’ meetings and did not know know where the minutes of these meetings were kept. The owner said the home does not collect any pensions or act as appointee for residents. He does hold some money for a small number of residents. The money and records are kept in the safe, the owner did not have the keys with him and therefore it was not possible to check these records. He said he keeps a record of all transactions and gives receipts to the residents representatvies. The home pays for additonal services, such as hairdressing, and the costs are included in a monthly invoice to residents and/or their representatives. The owner said he does not always record two signatures for cash transactions. A system for staff supervision has been put in place. A number of maintenance records were looked at and showed that the required maintenance and servicing of equipment is carried out. The records showed that hot water temperatures are checked monthly. The majority of staff are now up to date with moving & handling and fire safety training. The home has a trained moving and handling co-ordinator and a trained fire marshall. However some poor practice in moving and handling was observed during the visit and foot plates were not always used on wheelchairs. Three staff have up to date food hygiene training. Information provided by the home showed that seven staff have current First Aid certificates. The accidents records were looked at. One injury seen had only been recorded in the accident book; there was no evidence that the cause had been fully investigated. There is no system for auditing accidents. Pollard House DS0000056120.V297911.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 2 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 2 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 1 2 2 X 3 X 2 2 2 STAFFING Standard No Score 27 2 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 1 1 X 2 3 2 1 Pollard House DS0000056120.V297911.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4&5 Requirement The registered persons must review and update the Statement of Purpose and Service User Guide and must provide the CSCI with copies of the completed documents. Every service user must be given a copy of the Service Users Guide, which must include the Terms and Conditions of residency. Previous timescales of 24/03/06 & 31/05/06 not met. The terms and conditions must set out clearly the cost of additional services. The service users plans must set out in detail how personal, health and social care needs will be met. Timescale for action 15/09/06 2 OP2 5 15/09/06 3 4 OP2 OP7 5 15 15/09/06 15/09/06 5 OP8 12(1) & 17(1) Previous timescale of 28/04/06 not met. The registered persons must 15/09/06 make sure that the health care needs of residents are met and that this is accurately reflected in the care records. DS0000056120.V297911.R01.S.doc Version 5.2 Page 25 Pollard House 6 OP9 13(2) 7 OP9 13(2) & 17(1) 8 OP10 12(4) 9 OP12 16(2) The registered persons must make proper arrangements for the safe storage of medicines. (This refers specifically to the storage of Insulin) The registered persons must make sure that residents are given their prescribed medicines and that there are accurate records of all medicines administered. The registered persons must make sure that working practices promote the privacy and dignity of service users. The registered persons must provide a programme of activities that takes account of the needs, preferences and capabilities of service users. 14/06/06 18/08/06 15/09/06 15/09/06 10 OP15 16(2) Previous timescales of 28/10/05, 24/03/06 & 31/05/06 not met. The registered persons must 15/09/06 make sure that residents are given varied and nutritious meals that take account of their dietary needs and preferences. Previous timescales of 24/03/06 and 31/05/06 not met. The complaints procedure must 15/09/06 be made available to service users and/or their representatives in an appropriate format. The registered persons must 18/08/06 make sure that staff understand what constitutes abuse and know how to apply the Adult Protection procedures in practice. The registered persons must 15/09/06 make sure that the programme of maintenance and refurbishment is continued so that all parts of the home are in good state or repair. Furnishings and decoration must be DS0000056120.V297911.R01.S.doc Version 5.2 Page 26 11 OP16 22 12 OP18 13(6) 13 OP19 23(2) Pollard House maintained to a reasonable standard. Previous timescales of 30/11/05 and 26/05/06 not met. Doors must not be propped open using wedges. When doors need to be held open they must be fitted with door closure devices that are activated by the fire alarm. The gardens must be maintained in a suitable condition so that services users can use them. All parts of the home must be kept free of offensive odours. The registered persons must review the staffing levels to make sure there are always enough staff on duty to meet residents needs. The duty rosters must reflect accurately the staffing situation in the home. The registered persons must not employ people to work in the home until they have made sure that they have full and satisfactory information to support the fact that the applicant is a person of integrity and good character. Previous timescales of 31/12/04, 21/09/05, 24/02/06 and 31/05/06 not met. Staff must be given the training they need to meet the needs of residents; specifically this must include training on how to care for people with dementia. Records of all training, including induction, must be maintained. Previous timescales of 28/04/06 not met. Pollard House DS0000056120.V297911.R01.S.doc Version 5.2 Page 27 14 OP19 23(4) 28/07/06 15 16 17 OP20 OP26 OP27 23(2) 16(2) 18 28/07/06 28/07/06 18/08/06 18 OP29 19 18/08/06 19 OP30 18 18/08/06 20 OP31 8 21 OP32 26 22 OP33 24 The registered persons must appoint a manager and an application must be made to the CSCI to have the manager registered. The registered persons must provide the CSCI with reports of visits to the home carried out in accordance with this regulation. The registered persons must implement and maintain a quality assurance system based on seeking the views of service users. The findings of these reviews must be made available to service users. Previous timescale of 28/04/06 not met. The registered persons must maintain a record of all money and/or valuables held on behalf of service users and these records must be available for inspection. The home must have a photograph of every service user. Previous timescales of 28/10/05, 24/03/06 and 31/05/06 not met. The registered persons must make sure that all the records required by regulation are kept up to date and in good order and are available for inspection. The registered persons must make sure that staff adhere to safe practices when moving and handling service users. The accident records must include details of the action taken following the accident. The registered persons must provide the CSCI with a written improvement plan. The improvement plan must set out how they intend to make DS0000056120.V297911.R01.S.doc 28/07/06 28/07/06 15/09/06 23 OP35 17(2) 28/07/06 24 OP37 17(1)(a) 28/07/06 25 OP37 17 18/08/06 26 OP38 13(5) 28/07/06 27 28 OP38 *RQN 17(1) 24A 18/08/06 04/08/06 Pollard House Version 5.2 Page 28 improvements to the service and the timescale within which this will be achieved. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP3 Good Practice Recommendations The pre-admission assessment form should include information on where and when the assessment was carried out, who was consulted and who did the assessment. The home should consult with a dietician regarding the nutritional content of the menus. Information on the meals to be provided should be made available to residents in advance of meal times and they should be given the opportunity to choose what they want to eat. 50 of care staff should be qualified to NVQ level 2 or equivalent Accident records should be stored in individual files to comply with Data Protection law. Accident records should be analysed at least every month. 2 OP15 3 4 OP28 OP38 Pollard House DS0000056120.V297911.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Pollard House DS0000056120.V297911.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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